blood on head ct

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Blood on Head CT

Diane M. Birnbaumer, M.D., FACEPProfessor of MedicineUniversity of California, Los AngelesSenior FacultyDepartment of Emergency MedicineHarbor-UCLA Medical Center

Blood in the Head… Oh, My!

Is all blood in the head treated the same? (N.B. This lecture will focus on nontraumatic

intracranial bleeding)

Who needs blood pressure control?Who needs antiseizure medications?Who needs other interventions?

Intracranial Hemorrhage

Key Reference Morgenstern LB, et al: Guidelines for the

Management of Spontaneous Intracerebral Hemorrhage: A Statement for Healthcare Professionals from the American Heart Association / American Stroke Association. Stroke 2010;41:2108-2129.

Management of Spontaneous ICH

Guideline for diagnosis and treatment of spontaneous intracranial hemorrhage

Update of 2007 guideline Formal medical literature search used as basis of

guideline

Management of Spontaneous ICH: Background

Spontaneous ICH a significant cause of morbidity and mortality

Aggressive management and excellent medical care have significant impact on outcomes

Management of Spontaneous ICH: Emergency Diagnosis

Rapid diagnosis and management crucial Early deterioration is common – both prehospital

and after arrival Prehospital management is to provide

ventilatory and cardiovascular support and transport

Secondary goal is obtaining history, circumstances, etc.

Also, contact regarding imminent patient arrival

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ED Issues Should be prepared to manage or rapidly transfer Neurology, neuroradiology, neurosurgery and critical

care facilities crucial Focus on obtaining pertinent history

Time of onset, vascular risk factors, medications (esp. anticoagulants or antiplatelet agents), recent trauma or surgery, history of dementia, alcohol or drug use, seizures, liver disease, cancer


ED Issues Physical examination

Vitals, general examStructured neuro exam

(e.g. NIH Stroke Scale exam), GCS


ED Issues Tests

CBC, electrolytes, BUN/Cr, glucose, coagulation studies, tox screen, UA, urine culture, pregnancy test

ECGCXRNeuroimaging


ED Issues Management

Multiple issues and challengesFew standardized pathways used Issues:

BP management Intubation Reversal of coagulopathy Neuroimaging Definitive consultation and intervention


Neuroimaging Clinically very difficult to differentiate

ischemic from hemorrhagic neurovascular eventSome findings correlate with hemorrhage, but

findings are not specific enough to ICH Neuroimaging mandatory CT and MRI both reasonable first choices

CT current gold standardGradient echo and T2 susceptibility-weighted MRI

as sensitive as CT and more sensitive to predict prior hemorrhage


Patients at significant risk of hematoma expansion

Is predictive of clinical deterioration, increased morbidity and mortality

MRI / angiogram / venogram and CT angiogram / venogram sensitive in identifying secondary causes of hemorrhage (AVM, tumors, cerebral vein thrombosis) May be indicated if secondary causes suspected by

history, exam or radiographic findings

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Neuroimaging Recommendations: Rapid neuroimaging with CT or MRI recommended to

distinguish ischemic stroke from hemorrhage CT angiography and contrast-enhanced CT may help

identify patients at risk for hematoma expansion, and CT angio, CT venogram, contrast-enhanced CT,

contrast-enhanced MRI, MRA, and MRV may be useful to find underlying structural lesions

Management of Spontaneous ICH: Medical Treatment

Hemostasis / Antiplatelets / DVT Prophylaxis Coagulopathy contributes significantly to ICH Patients on oral anticoagulants with

life-threatening bleeding should be normalized as soon as possible

Vitamin K and FFP are traditional Prothrombin complex concentrates (PCCs)

and recombinant factor VIIa are potential therapies


Hemostasis / Antiplatelets / DVT Prophylaxis Prothrombin complex concentrates (PCCs)

Plasma-derived factor concentratesContains primarily factor IX, but also II, VII and X Increasingly recommended for warfarin reversalBenefits

Can be administered rapidly High concentrations of factors in small volumes

Can rapidly normalize INR (minutes) Faster than Vitamin K and FFP

Use is increasingly being recommended


Hemostasis / Antiplatelets / DVT Prophylaxis Recombinant factor VIIa

Potential treatment in patients on oral anticoagulants (OACs)

Can rapidly normalize INR, but does not replenish vitamin K-dependent factors

May not restore thrombin generation as well as PCCs

NOT recommended for use in recent review by American Society of Hematology for warfarin reversal – even for ICH patients not on OACs


Hemostasis / Antiplatelets / DVT Prophylaxis Antiplatelet agents

Results conflicting Data conflicting on effect of platelet transfusions in

ICH patientsTrue effect not known at this time


Hemostasis / Antiplatelets / DVT Prophylaxis High risk of thromboembolic disease in ICH patients Intermittent pneumatic compression with elastic

stockings shown effective at reducing risk of symptomatic DVT

Role of additional anticoagulant unclear but no harm seen if ICH is stable

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Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations: If severe coagulation factor deficiency or

thrombocytopenia, receive factor replacement or platelets, respectively

If on warfarin, withhold warfarin, replace factors with FFP and give IV vitamin KPCCs are a reasonable method of

replacement as alternative to FFPRecombinant factor VIIa not routinely

recommended as sole agent


Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations: Recombinant Factor VIIa also not recommended in

noncoagulopathic ICH patients Platelet transfusions in patients on antiplatelet agents

is considered investigational


Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations: Patients with ICH should have intermittent pneumatic

compression and elastic stockings for DVT prevention Low-dose subcutaneous LMWH or UFH can be

considered for DVT prevention 1 to 4 days after ICH onset


Blood Pressure Blood pressure frequently elevated after ICH “Ischemic penumbra” not seen in ICH (versus in

ischemic stroke, where it is an issue) INTensive Blood Pressure Reduction in Acute Cerebral

Hemorrhage Trial (INTERACT) ICH patients assessed, monitored and treated

within 6 hours of onset of bleedRandomized to placebo versus intravenous BP-

lowering agents to different target blood pressures


Blood Pressure INTensive Blood Pressure Reduction in Acute Cerebral

Hemorrhage Trial (INTERACT)Study showed a trend toward lower ICH growth in

intensively managed groupNo downside seen in this groupData insufficient to recommend definitive policyGuideline does present suggested management


Blood Pressure Recommendations Management of BP based on incomplete efficacy

evidence Recommendations:

SBP > 200mmHg or MAP > 150mmHg, consider aggressive reduction with IV meds and monitor BP every 5 minutes

IF SBP > 180mmHg or MAP > 130mmHg and there is a possibility of elevated ICP, consider monitoring ICP and reducing BP by intermittent or continuous IV medications – CPP goal ≥ 60mmHg

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Blood Pressure Recommendations (cont.) Recommendations:

If SBP > 180mmHg or MAP > 130mmHg and no evidence of elevated ICP, consider modest reduction of BP (e.g. to MAP of 110mmHg or target BP 160/90) using intermittent or continuous IV meds and reexamine patient every 15 minutes

In patients presenting with SBP 150-220mmHg, acutely lowering BP to 140mmHg probably safe


Inpatient Management and Prevention of Secondary Brain Injury Should be admitted to neuroscience ICU Frequent assessment needed Nurses skilled in caring for ICH

patients critical part of the patient’s care – improves outcomes

Documentation includes vitals, detailed assessment of neurological function

Bottom line: Admit to neuroscience ICU


Management of Glucose Elevated blood glucose correlates

with increased mortality risk, but tight control risks hypoglycemic events

Optimal management currently unknown

Hypoglycemia should be avoided Recommendation: Glucose

should be monitored and normoglycemia is recommended


Temperature Management Presence of fever correlates with worse

outcomes However, no data links fever treatment to

outcome Cooling has not been

systematically investigated


Seizures and Antiepileptic Drugs Clinical seizures should be treated Continuous EEG monitoring probably indicated if

depressed mental status out of proportion to degree of brain injury

If found to have seizures on EEG, should be treated with antiepileptic drugs

Prophylactic anticonvulsants should not be used


ICP Monitoring / Treatment If hematoma small and IVH limited, treatment to

lower ICP usually not warranted Even in serious ICH, management of elevated ICP

shows minimal impact on outcome ICP measuring devices are invasive and pose

potential for complications If used, coagulation status should be evaluated and

deficits corrected Consider ICP monitoring if GCS ≤ 8, clinical evidence

of herniation, significant IVH or hydrocephalus

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ICP Monitoring / Treatment Recommendations

If GCS ≤ 8, clinical evidence of transtentorial herniation, significant IVH or hydrocephalus, consider ICP monitoring and treatment

Goal is cerebral perfusion pressure of 50-70 mmHgVentricular drainage as treatment for

hydrocephalus is reasonable in patients with decreased level of consciousness


Intraventricular Hemorrhage Occurs in 45% of spontaneous ICH patients Most are secondary – related to

hypertensive hemorrhages involving basal ganglia and the thalamus

Theoretical advantage of using thrombolytics to lyse intraventricular clot

Minimal data on efficacy and outcomes Recommendation: Efficacy and safety of

thrombolytics in IVH uncertain, considered investigational


Clot removal Surgical treatment remains controversial Balance of limiting mechanical damage to surrounding

tissue with risk of ongoing bleeding Often need to cut through uninjured brain to get to

ICH, increasing potential for damage


Clot removal Most data exists on clot removal in cerebellar

hemorrhage (10-15% of ICHs) If larger than 3cm or with brainstem compression or

hydrocephalus – good outcomes with surgery (compared to those with medical management)

Not from randomized, controlled trials Other locations have variable results with surgery,

including some with worse outcomes


Minimally invasive surgical clot removal Techniques available

Stereotactic guidance combined with either thrombolytic-enhanced or endoscopic-enhanced aspiration

Trials show decreased mortality if done within 12-72 hours, but improved functional outcome not consistently demonstrated


Timing of surgical intervention Variance between studies makes

drawing conclusions difficult Very early surgery (4 hours or less)

shows worse outcomes Surgery less than 12 hours shows

mixed results No clear timing benefit between 24,

48, 72, or 96 hours

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Surgery Recommendations: For most patients, usefulness of surgery is uncertain If cerebellar bleed deteriorating neurologically or with

brainstem compression or hydrocephalus – should undergo surgical decompression

If clot > 30mL and within 1cm of surface, surgery may be considered

Minimally invasive clot evacuation is considered investigational

No evidence that surgery improves functional outcome; very early surgery may be harmful


Outcome prediction and withdrawal of support Should avoid creating a self-fulfilling prophecy of

guaranteed poor outcome Although outcomes are poor, some patients have

functional survival Recommendation

Aggressive, full care early after ICH (unless preexisting DNR)

New DNR orders should be postponed until after day 2, at the earliest


Prevention of Recurrent ICH Recurrence rate 2.1-3.7% per patient-year for survivors There are some identified risk factors

Lobar locationOlder ageOngoing anticoagulationPresence of specific allelesGreater number of microbleeds on MRI

Long term blood pressure control is recommended


Prevention of Recurrent ICH (cont.) Anticoagulant use associated with worse bleeds and

risk of recurrence Must decide whether benefit outweighs risk Frequent alcohol use tied to increased risk of rebleed Unclear benefit of using statins No recommendations can be made regarding

exertional activities


Rehabilitation and Recovery Studies problematic as they mix ischemic stroke, SAH

and ICH patient populations Half of survivors of ICH remain dependent on others Recovery may continue indefinitely Well-organized, multidisciplinary inpatient stroke units

improve recovery Recommendation

Reasonable that all patients with ICH have multidisciplinary rehabilitation

If possible, should be started as early as possible and continued through discharge and home care

Management of Spontaneous ICH: Summary

Neuroimaging recommendations Rapid neuroimaging with CT or MRI

recommended to distinguish ischemic stroke from hemorrhage

CT angiography and contrast-enhanced CT may help identify patients at risk for hematoma expansion, and

CT angio, CT venogram, contrast-enhanced CT, contrast-enhanced MRI, MRA, and MRV may be useful to find underlying structural lesions

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Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations: If severe coagulation factor deficiency or

thrombocytopenia, give factor replacement or platelets, respectively

If on warfarin, withhold warfarin, replace factors with FFP and give IV vitamin KPCCs are a reasonable method of

replacement as alternative to FFPRecombinant factor VIIa not routinely

recommended as sole agent


Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations: Recombinant Factor VIIa also not

recommended in noncoagulopathic ICH patients

Platelet transfusions in patients on antiplatelet agents is considered investigational


Hemostasis / Antiplatelets / DVT Prophylaxis Recommendations Patients with ICH should have

intermittent pneumatic compression and elastic stockings for DVT prevention

Low-dose subcutaneous LMWH or UFH can be considered for DVT prevention 1 to 4 days after ICH onset


Blood Pressure Recommendations SBP > 200mmHg or MAP > 150mmHg,

consider aggressive reduction with IV meds and monitor BP every 5 minutes

If SBP > 180mmHg or MAP > 130 mmHg and there is a possibility of elevated ICP, consider monitoring ICP and reducing BP by intermittent or continuous IV medications – CPP goal ≥ 60mmHg


Blood Pressure Recommendations (cont.) If SBP > 180mmHg or MAP > 130mmHg

and no evidence of elevated ICP, consider modest reduction of BP (e.g. to MAP of 110mmHg or target BP 160/90) using intermittent or continuous IV meds and reexamine patient every 15 minutes

In patients presenting with SBP 150-220 mmHg, acutely lowering BP to 140mmHg probably safe


Admission Recommendations Patients should be admitted to

neuroscience ICUs Outcomes improved

Glucose Management Optimal management of hyperglycemia

needs to be clarified Glucose should be monitored and

normoglycemia is recommended Hypoglycemia should be avoided

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Seizures and antiepileptic drugs Clinical seizures should be treated Continuous EEG monitoring probably

indicated if depressed mental status out of proportion to degree of brain injury

If found to have seizures on EEG, should be treated with antiepileptic drugs

Prophylactic anticonvulsants should not be used


ICP Monitoring / Treatment Recommendations If GCS ≤ 8, clinical evidence of

transtentorial herniation, significant IVH or hydrocephalus, consider ICP monitoring and treatment

Goal is cerebral perfusion pressure of 50-70mmHg

Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness


Intraventricular Hemorrhage Recommendations Efficacy and safety of thrombolytics

in IVH uncertain, considered investigational


Surgery Recommendations: For most patients, usefulness of surgery is

uncertain If cerebellar bleed deteriorating

neurologically or with brainstem compression or hydrocephalus –should undergo surgical decompression

If clot > 30mL and within 1cm of surface, surgery may be considered


Surgery Recommendations (cont.): Minimally invasive clot evacuation is

considered investigational No evidence that surgery improves

functional outcome; very early surgery may be harmful


Outcomes Aggressive support should be provided

for at least the first 2 days unless already DNR

No DNR decisions should be made in the first 2 days

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Prevention of Recurrence Increased risk if lobar location, older age,

ongoing anticoagulation, microbleeds BP should be well-controlled (to < 140/90)

after initial period Avoid anticoagulation for nonvalvular atrial

fibrillation Avoid heavy alcohol use No evidence regarding restrictions on

statin use or strenuous activity


Rehabilitation and Recovery Recommendations Reasonable that all patients with ICH have

multidisciplinary rehabilitation If possible, should be started as early as

possible and continued through discharge and home care

Subarachnoid Hemorrhage

Key Reference Connolly ES, et al: Guidelines for the

Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke June 2012


Prior guidelines issued 1994 and 2009 Current guidelines includes data through

2010


Potentially devastating cause of intracranial bleeding

Most caused by aneurysms 12-15% die before reaching hospital 6-10% of survivors functionally

dependent Another 15% have significant lifestyle

changes


Workup recommendations Maintain high level of suspicion in patients

with severe headache Noncontrast CT; if nondiagnostic, perform

LPMRI adjunct imaging test; negative test still

necessitates LP

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Rebleeding associated with high mortality / poor prognosis

Risk maximal first 2-12 hours 4-13.6% rebleed in first 24 hoursOne third of rebleeds occur in first 3 hours Half within first 6 hours Early rebleeding has poorer prognosis


Factors associated with rebleedingWorse neuro status on admission Longer time to aneurysm treatment Initial loss of consciousness Previous sentinel headaches Larger aneurysm size Possibly systolic blood pressure


For rebleed prevention Control blood pressure ASAP with titratable

agent Magnitude of lowering unclear, but consider

SBP < 160 mm Hg If unavoidable delay of aneurysm

obliteration (> 72 hrs), significant risk of rebleed and no contraindications, consider tranexamic acid or aminocaproic acid


Cerebral vasospasm after SAH common Narrowing of visible cerebral arteries

occurs 7-10 days after rupture Resolves spontaneously within 21 days Causes diffuse cerebral ischemia A major cause of death and disability

associated with SAH


For vasospasm/diffuse cerebral ischemiaOral nimodipine in all patientsMaintain euvolemiaMaintain normal circulating blood volume CT or MRI useful to identify regions of

potential brain ischemia If DCI, consider inducing hypertension


Up to one quarter of SAH patients have seizures Not clear they are all epileptic in origin

Delayed seizures in 3-7% Short term prophylaxis used Based on concept that seizures could lead to

additional injury / rebleed Data weakly supportive of this practice

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Long term seizure treatment has not shown any significant effect on outcome

Potential side effects do not appear to outweigh benefits


Seizure treatment Consider prophylactic anticonvulsants in

immediate post-hemorrhage period Routine long term use not recommended

Special circumstances: Prior seizures, intracerebral hematoma, intractable hypertension, infarction, MCA aneurysm


Medical complications common Electrolyte abnormalities Fever Hyperglycemia Anemia DVT


Electrolyte abnormalities Hyponatremia

Seen in 10-30% of casesRelease of natriuretic peptides “Cerebral salt wasting”Recommendations

Avoid large volume hypotonic fluids Avoid intravascular volume contraction Monitor fluid status (central line) Use crystalloid or colloid for volume contraction


Fever (central origin) Independently associated with worse

cognitive outcome Control of fever may improve outcome Recommendation

Aggressive control of feverTarget is normothermiaMay need standard or advanced approaches


Elevated blood glucose Relatively common Associated with poor outcome No proof aggressive glucose control

improves outcomes Hypoglycemia should be avoided

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Anemia Higher hemoglobin levels associated with

improved outcomesOptimal hemoglobin level unclear Consider transfusing pRBCs in patients at

risk for cerebral ischemia (larger bleeds, demonstrated spasm on imaging studies)


Miscellaneous recommendations If < 10 SAH cases each year, transfer to

institution with experience treating > 35 per year

Subarachnoid HemorrhageSummary

Workup recommendations Maintain high level of suspicion in

patients with severe headache Noncontrast CT; if nondiagnostic,

perform LPMRI adjunct imaging test;

negative test still necessitates LP


For rebleed prevention Control blood pressure ASAP

with titratable agent Magnitude of lowering unclear,

but consider SBP < 160 mm Hg


For vasospasm/diffuse cerebral ischemiaOral nimodipine in all patientsMaintain euvolemiaMaintain normal circulating blood

volume CT or MRI useful to identify regions of

potential brain ischemia If DCI, consider inducing hypertension


Seizure treatment Consider prophylactic

anticonvulsants in immediate post-hemorrhage period

Routine long term use not recommended

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Managing medical complications Hyponatremia

Avoid large volume hypotonic fluidsAvoid intravascular volume

contractionMonitor fluid status (central line)Use crystalloid or colloid for volume

contraction


Managing medical complications Fever recommendation

Aggressive control of feverTarget is normothermiaMay need standard or advanced

approaches


Managing medical complications Hypoglycemia should be avoided Consider transfusing pRBCs in

patients at risk for cerebral ischemia


If < 10 SAH cases each year, transfer to institution with experience treating > 35 per year

Thank You For Your Attention

Any Questions?

blood on head ct

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